Moving Beyond Cultural Competency

Recent attempts by the medical establishment to address cultural issues in health have consisted of teaching and learning skills of "cultural competency." However, this approach does patients injustice as it over-generalizes culture and dismisses the clinician's own cultural biases as irrelevant. A more beneficial approach is outlined.By Emmy Shearer, published 11/08/2013

Over the past two decades, there has been an increased demand for what is known as "cultural competency" in the medical profession. Cultural competency, scholars and human-rights advocates assert, is necessary because culture shapes health-care related beliefs and behaviors — and thus should shape diagnosis, treatment and care. Advocates of this paradigm point to real-life cases where a lack of cultural understanding has hindered doctor-patient relationships. For example, persons of certain Asian ancestries have at times refrained from complying with prescriptions for "hot" medicines such as ARVs to treat "hot" diseases such as HIV/AIDS: in their culture, "hot" diseases can only be cured with "cold" food and medicines. In response, many medical schools, including top institutions such as Columbia and UCSF, have instituted cultural competency as part of their curriculum. However, what these proponents gain in increased attention to cultural differences, they lose in problems of ecological fallacy and generalization. First, the term "cultural competency" reduces cultural understanding to a problem that can be overcome with proper training. It assumes people of one race or ethnicity will all react or behave to a health event in similar fashions. In the biomedical paradigm clinicians are trained in, culture then becomes just another "factor" that must be accounted for in diagnosis and treatment. However, culture is continually changing and encompasses much more than merely "ethnicity" or "race." By confining culture to within these narrow frames and over-generalizing cultures to ethnic or racial groups, physicians and other health professionals risk getting tunnel-vision, blind to other social determinants of health that may be acting subversively. Moreover, by claiming "cultural competency" as a skill to be acquired, it is implied that patients are the only ones with a "culture" that must be accounted for. However, medical professionals also have relevant cultural beliefs and attitudes that may color how they engage with patients, whether consciously or otherwise. Doctor-patient relationships are two-way, and must be acknowledged as such if doctors want to truly get at the root of patient complaints. So how do we proceed? I propose that an explanatory model, as proposed by Kleinman et al. put forth, be considered as a replacement to traditional courses in cultural competency.[1] In this model, a physician uses a series of open-ended questions in order to open a discussion that can put his or her expert knowledge alongside the experiences and explanations of the patient. Questions Kleinman et al. put forth as examples include, "What do you believe is the cause of this problem?", "How does it affect your body and mind?", and "What do you fear most about treatment?" These questions necessarily address cultural issues, but avoid pigeonholing and top-down lecturing by placing them within the narrower context of the individual patient. By embracing this model, we can move forward from defining a patient as a "case" to acknowledging them as a unique individual, both in beliefs and in physiology. In this way, we can make important strides in improving patient care.